Gerlach et al.

BMC Neurology 2012, 12:13

http://www.biomedcentral.com/1471-2377/12/13

RESEARCH ARTICLE Open Access

Deterioration of Parkinson’s disease during

hospitalization: survey of 684 patients
Oliver HH Gerlach1*, Martijn PG Broen1, Peter HMF van Domburg2, Ad J Vermeij3 and Wim EJ Weber1

Abstract
Background: A substantial fraction of Parkinson’s disease patients deteriorate during hospitalisation, but the
precise proportion and the reasons why have not been studied systematically and the focus has been on surgical
wards and on Accident & Emergency departments. We assessed the prevalence and risk factors of deterioration of
Parkinson’s disease symptoms during hospitalization, including all wards.
Methods: We invited Parkinson’s disease patients from three neurology departments in The Netherlands to answer
a standardised questionnaire on general, disease and hospital related issues. Patients who had been hospitalized in
the previous year were included and analysed. Possible risk factors for Parkinson’s disease deterioration were
identified. Proportions were analysed using the Chi-Square test and a logistic regression analysis was performed.
Results: Eighteen percent of 684 Parkinson’s disease patients had been hospitalized at least once in the last year.
Twenty-one percent experienced deterioration of motor symptoms, 33% did have one or more complications and
26% had received incorrect anti-Parkinson’s medication. There were no statistically significant differences for these
variables between admissions on neurologic or non-neurologic wards and between having surgery or not.
Incorrect medication during hospitalization was significantly associated with higher risk (OR 5.8, CI 2.5-13.7) of
deterioration, as were having infections (OR 6.7 CI 1.8-24.7). A higher levodopa equivalent dose per day was a
significant risk factor for deterioration. When adjusting for different variables, wrong medication distribution was
the most important risk factor for deterioration.
Conclusions: Incorrect medication and infections are the important risk factors for deterioration of Parkinson’s
disease patients both for admissions with and without surgery and both for admissions on neurologic and non-
neurologic wards. Measures should be taken to improve care and incorporated in guidelines.

Background not have proper guidelines yet to prevent worsening of

Parkinson’s disease (PD) patients are admitted to hospi-
tals more frequently and longer than the general popula-
tion [1,2]. Up to a quarter of the total PD patients are
hospitalized each year [1]. There is general consensus
that a substantial fraction of these hospitalized PD
patients do deteriorate, but the precise proportion and
the reasons why have not been studied systematically
and the focus has been on surgical wards and on Acci-
dent & Emergency departments [3-6]. We found that,
although many PD patients seem to deteriorate during
hospitalization and there is concern about the quality of
care provided to these patients [7], most hospitals do
* Correspondence: o.gerlach@mumc.nl
1
Section of Movement Disorders, Department of Neurology, Maastricht
University Medical Centre, Maastricht, The Netherlands
Full list of author information is available at the end of the article
PD symptoms and complications during hospitalization
[8]. Before such guidelines can be formulated, a better
understanding of the problems encountered during hos-
pitalization of this group of patients is warranted. Our
aim in this study was to assess the prevalence and risk
factors of deterioration in hospitalized PD patients
including all wards.
Methods
PD patients from 3 neurology departments in the south-
ern part of The Netherlands were invited to participate
in the survey, i.e. the Maastricht University Medical
Centre in Maastricht, Orbis Medical Centre in Sittard-
Geleen, and Catharina Hospital Eindhoven in Eindho-
ven. Only PD patients, of whom the diagnosis had been
confirmed by a neurologist according to the UK Brain

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Gerlach et al. BMC Neurology 2012, 12:13
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Bank criteria were selected. All patients with other or
unclear parkinsonisms were excluded. The selected
patients were sent a questionnaire by mail. This ques-
tionnaire consisted of questions concerning general, per-
sonal and disease related issues (see additional file 1 and
2). Patients were asked whether or not having cognitive
problems. The obtain more accurate data, we asked
patients to fill in the questionnaire with the help of a
caregiver. Patients who confirmed that they had been
admitted to a hospital in the previous year, were asked
to answer more detailed questions about this hospital
stay (e.g. exact timing or lack of drug administration,
complications, and PD deterioration). After 4 weeks we
sent a reminder to patients who had not yet returned
the questionnaire. We validated the data by comparing
the questionnaire-replies with corresponding hospital
records. Only patients with a hospital submission in the
previous year were included and analysed. Admissions
for PD related brain surgery were excluded. Subse-
quently, we tried to identify possible risk factors for PD
deterioration.
PD deterioration we defined as decline in motor func-
tion. Receiving incorrect PD medication during the hospi-
tal stay was defined as administration of PD drugs during
the hospital stay not as home schedule with attention to
interruption, wrong timing, and different PD medication.
Levodopa Equivalent Dose (LED) was used to calculate
the amount of anti-parkinsonian drugs [9].
The ethics committees of the 3 collaborating hospitals
approved our study: Medical Ethics Committee aca-
demic hospital Maastricht/Maastricht university (refer-
ence number 08-5-082), Local Advisory Group Scientific
Research Orbis Medical Centre (reference number
10.029), and Medical Ethics Committee Catharina Hos-
pital Eindhoven (reference number M11-015). Research
was carried out in compliance with the Helsinki
Declaration.
Statistical methods
We compared proportions using the Chi-Square test for
independence and subsequently performed a logistic
regression analysis. A P-value of less than 0.05 is consid-
ered statistically significant. Admissions were not
included if there were data missing required for that
specific analysis. All statistical analysis are performed
with PASW-version 18.0 (SPSS, Chicago).
Results
Response rate
We invited 884 patients to participate, and data from
684 patients (response rate 77%) were available for this
study (Table 1). In total 123 patients were admitted to
hospital in the previous year, accounting for 159 admis-
sions, and these were used for analysis. 60% of the PD
Page 2 of 6
patients filled in the questionnaire together with a
caregiver.
Hospitalization
Eighteen percent of the PD patients were hospitalized at
least once in the last year with an average of 1.3 (ran-
ging between one and four) admissions per patient per
year. Patients were admitted most frequently on a non-
neurological ward, being surgery (24%), internal medi-
cine (22%), orthopaedics (15%), urology (13%), cardiol-
ogy (11%) and others. Admission reasons for these
wards were traumatic injury whether or not following
surgery (20%), urinary tract problems (15%), gastroin-
testinal problems (15%), cardiac problems (12%), other
surgical procedures (11%), elective joint replacement
due to arthrosis (7%), pneumonia (6%), and others. Eigh-
teen percent of the patients were admitted to a neurolo-
gical ward. Of those, 71% had PD related problems (45%
PD medication problems, 20% deterioration of PD, 10%
PD related screening, 5% hallucinations/confusion, 5%
swallowing problems, 15% unknown). Other reasons for
admission to a neurological ward were mainly strokes.
More than a fifth of all patients experienced deteriora-
tion of motor PD symptoms during their hospital stay.
Forty-four percent of them showed no complete recovery
after discharge. Most patients stated to have an overall
worsening of motor function (38%) or motor skills (32%).
The other ones had a worsening of rigidity (12%), tremor
(9%), balance problems (3%), or bradykinesia (3%).
For the group of patients that were admitted because
of PD deterioration, one patient further deteriorated
during this admission. This patient didn’t receive correct
PD medication.
A third of the patients did have one or more compli-
cations during the admission, mainly confusion followed
by infections. Complications didn’t differ between non-
neurologic and neurologic wards (P = 0.83). There was
not more confusion (P = 0.80) or other statistically sig-
nificant differences in complication rates among patients
whether or not having surgery. Of the patients having
an infection as a complication during admission, non of
them had an infection as admission reason.
More than a quarter of the patients reported receiving
incorrect PD medication during the hospital stay, i.e.
wrong timing (79%), different PD medication (29%) or
interruption of PD medication (5%). No difference in
medication distribution problems between neurologic
and non-neurologic wards (P = 0.49) or whether or not
patients having surgery (P = 0.07) was found. In 3%
there was self-administration of PD drugs.
Deterioration and relating factors
With respect to the general and PD related characteris-
tics only for patients with a LED-value of more than
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Table 1 Patient and hospitalization characteristics

MUMC OMC CHE Total Homogeneity$
Total questionnaires (N) 447 230 207 884
Response rate (%) 72 84 81 77
Admitted patients (N) 53 34 36 123
Total hospitalizations (N) 61 47 51 159
Age (yr) 71 [SD = 10.4] 75 [SD = 7.6] 71 [SD = 8.5] 72 [SD = 9.2] 0.87
Disease duration (yr) 9.6 [SD = 7.0] 9.1 [SD = 7.2] 10.7 [SD = 6.9] 9.8 [SD = 7.0] 0.49
LED-value (mg/day) 554 761 855 711 0.004
N* %* N* %* N* %* N* %*
Gender
Women 28 46 15 32 14 28 57 36 0.04
Men 33 54 32 68 37 72 102 64
Hoehn&Yahr
stage < III 24 39 20 43 13 25 57 36 0.12
stage III, IV 33 54 25 53 33 65 91 57 0.32
stage V 3 5 2 4 5 10 10 6 0.33
Don’t know/missing 1 2 0 0 0 0 1 1
On-off fluctuations
Yes 27 44 14 30 21 41 62 39 0.61
No 33 54 33 70 30 59 96 60
Don’t know/missing 1 2 0 0 0 0 1 1
Cognitive problems
Yes 20 33 24 51 29 57 72 46 0.009
No 41 67 23 49 22 43 86 54
Don’t know/missing 0 0 0 0 0 0 0 0
Deterioration during admission
Yes 13 21 10 21 11 22 34 21 0.84
No 45 74 30 64 35 69 110 69
Don’t know/missing 3 5 7 15 5 10 15 9
Complications during admission
None 40 66 30 64 35 69 105 66 0.76
One or more complications 21 34 15 32 16 31 52 33 0.30
Confusion 13 21 11 23 11 22 35 22 0.91
Urinary tract infection 4 7 6 13 2 4 12 8 0.70
Emotional disturbance 6 10 0 0 0 0 6 4 0.004
Pneumonia 0 0 2 4 2 4 4 3 0.17
Memory complaints 2 3 0 0 3 6 5 3 0.50
Falls 0 0 2 4 0 0 2 1 0.87
Other 2 3 0 0 3 6 5 3 0.50
Don’t know/missing 0 0 2 4 0 0 2 1
Medication distribution
Good 40 66 29 62 39 76 108 68 0.15
Bad 18 30 16 34 8 16 42 26
Don’t know/missing 3 5 2 4 4 8 9 6
Surgery
Yes 39 64 21 45 31 61 91 57 0.63
No 22 36 26 55 20 39 68 43
Don’t know/missing 0 0 0 0 0 0 0 0
Ward
Neurologic 11 18 6 13 11 22 28 18 0.68
Non-neurologic 48 79 41 87 39 76 128 81
Don’t know/missing 2 3 0 0 1 2 3 2
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Table 1 Patient and hospitalization characteristics (Continued)

Involvement of paramedics
Yes 23 38 29 62 8 16 60 38 0.025
No 34 56 14 30 41 80 89 56
Don’t know/missing 4 7 4 9 2 4 10 6
Consultation of PD nurse specialist#
Yes 14 23 20 43 5 10 39 25 0.14
No 45 74 24 51 44 86 113 71
Don’t know/missing 2 3 3 6 2 4 7 4
* N; number and percentage of total admissions
#
Non-neurological ward
$ For homogeneity between different centres the Pearson Correlation and Spearman’s rho tests were used. P-values are shown. P-value < 0.05 is considered
significant.
Abbreviations: MUMC, Maastricht University Medical Centre; OMC, Orbis Medical Centre; CHE, Catharina Hospital Eindhoven; N, number; SD, standard deviation;
LED-value, Levodopa Equivalent Dose; PD, Parkinson’s disease

700 mg/day there is a significantly increased risk for Table 2 Effect of patient, Parkinson’s disease
deterioration of PD symptoms (Table 2). characteristics, and factors during hospitalization on
As to hospital related risk factors incorrect medication deterioration of Parkinson’s disease
administration during hospitalization was significantly Deterioration
associated with deterioration during admission. This was (N = 34)
also the case when one or more complications occurred. Possible risk factors N P-value* OR [95%-
CI]
Analysing the individual complications, only infections
Gender
showed to be an significantly increased risk factor. No
Male 25 0.39
other variables were significant.
Age
In 14% of the admissions, PD patients had both cogni-
≥ 70 years 20 0.42
tive problems and didn’t have the help of a caregiver to
≥ 80 years 5 0.47
fill in the questionnaire. When excluding this group of
≥ 85 years 5 0.13
patients, since the reported data maybe less reliable,
Disease duration
both medication problems during admission (p = 0.00,
≥ 8 years 17 0.82
odds-ratio 6.0, 95%-confidence interval 2.4-14.9) and a
≥ 10 years 9 0.18
LED-value of more than 600 mg/dag (p = 0.024, odds-
≥ 12 years 8 0.36
ratio 3.25, 95%-confidence interval 1.2-9.0) are signifi-
Hoehn&Yahr
cant risk factors for deterioration, and infections aren’t
stage ≥ II 27 0.50
(p = 0.08).
stage ≥ III 27 0.07
When adjusting for possible confounders (logistic
On-off fluctuations 16 0.38
regression was applied using the following variables:
Cognitive problems 19 0.18
Age, gender, PD duration, LED-value, Hoehn& Yahr
LED-value
scale, presence of cognitive problems, recruitment cen-
> 500 mg/day 15 0.60
tre, wrong medication distribution, complications, infec-
> 600 mg/day 15 0.07
tions, surgery, non-neurologic ward admission,
> 700 mg/day 15 0.003 4.4 [1.7-11.5]
consultation of PD nurse specialist and involvement of
Complications ≥ 1 16 0.04 2.5 [1.1-5.6]
paramedics), there was still a significantly increased risk
Confusion 10 0.23
of deterioration in PD patients who had received incor-
Infections 7 0.00 6.7 [1.8-24.7]
rect medication (P = 0.042).
wrong medication distribution 18 0.00 5.8 [2.5-13.7]
surgery 17 0.26
Validation
Non-neurologic ward 27 0.60
We were able to retrieve clinical files of 84 (52%) admis-
No involvement of paramedics 16 0.15
sions. Most of the other files got lost because of an
No-consultation of PD nurse 17 0.04 0.3 [0.1-0.7]
intermittent change in computerized medical systems. specialist#
In those files, which thus comprise a sample half the
*P-value < 0.05 is considered significant
size of our patient sample, a doctor only once documen- #
Non-neurological ward
ted deterioration of PD. There was no report of dete- Abbreviations: N, number; OR, Odds-ratio; 95%-CI, 95%-confidence interval;
rioration by a nurse (vs. 34 by the patients). PD LED, Levodopa equivalent dose; PD, Parkinson’s Disease
Gerlach et al. BMC Neurology 2012, 12:13
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medication distribution problems were mentioned 7
times by a doctor and 12 times by a nurse (vs. 42 by the
patients). Urinary tract infections were reported 8 times
(vs. 12), confusion 13 times (vs. 35), pneumonia 3 times
(vs. 4) and furthermore 3 others.
Discussion
We sought to assess the prevalence and risk factors of
deterioration in hospitalized PD patients, as evidence sug-
gests that a substantial proportion of PD patients actually
worsen when admitted to a hospital [1,2]. In our popula-
tion of 684 PD patients almost one fifth had been hospi-
talized in the last year. Traumatic injury, infections,
direct PD-related problems, and problems with the circu-
latory and digestive system were the main admission rea-
sons, which accords with prior literature [1,2]. As in
those studies, confusion and infections were the most
common complications during hospitalization [1].
To our knowledge this is the first study systematically
analysing different risk factors for deterioration of PD
patients both for admissions with and without surgery.
There have been earlier studies documenting high
rates of incorrect medications given to hospitalized PD
patients, some as high as 74%. All these, on surgical
wards and on Accident & Emergency departments,
found that this was associated with deterioration, but to
varying degrees. All these studies were retrospective,
and selection of the patient sample was unclear [3-5].
We found having surgery or not did no matter in terms
of medication distribution problems or complications.
Somewhat unexpected, neurology wards do not do bet-
ter, as there was no statistically significant difference
between different wards regarding problems with medi-
cation distribution, complications, and PD deterioration.
There is one retrospective study suggesting that pre-
operative or immediate post-operative neurological con-
sultation of PD patients having surgery may result in
higher post-operative improvement of total Unified Par-
kinson’s Disease Rating Scale with most effect on activ-
ities on daily living [6]. In our study PD nurse specialists
(as part of the movement disorder teams) were involved
in a quarter of the admissions on a non-neurological
ward. This was associated with a higher risk on dete-
rioration during these admissions. This is probably
reverse causation, since PD nurse specialists were asked
to see the patient when deterioration had already
occurred.
Second to medication distribution problems with a 5.8
higher risk on deterioration, complications are signifi-
cantly related to PD deterioration, with infections as
mean factor with an increased risk of 6.7. Paramedic
care did not appear to be of influence. When analysing
different patient and PD related factors in relation to
Page 5 of 6
deterioration, only a LED-value above > 700 mg/day
showed to be a significant risk factor. For higher age
and higher Hoehn and Yahr scores there was a tendency
towards, but not a significantly, higher risk. When
excluding those patients who had no help with answer-
ing the questionnaire and had cognitive problems, only
wrong medication distribution and a LED-value of more
than 600 mg/dag are significant risk factors.
There are significant differences for some variables
between the hospitals which can be expected since the
Maastricht University Medical Centre is, unlike the
others, an university hospital (with more complex PD
patients and more patients with deep brain stimulation).
There is however no significant difference between the
centres in medication distribution problems.
When correcting for different variables, including
those that were significant different between the three
centres, wrong medication distribution is the most
important significantly increased risk factor for dete-
rioration. Comparing our data with data on medication
errors in hospitalized patients in general, showing medi-
cation errors on average in 6 per 100 hospitalized
patients, this study supports the higher vulnerability of
PD patients [10].
When validating the reported data by PD patients with
clinical files of the admissions there seems to be mainly
a strong underreporting of deterioration of PD support-
ing the lack of knowledge of this problem.
Apparently much more needs to be done to prevent
incorrect medication distribution and complications.
Better education of health care professionals, both on a
neurological and non-neurological wards, to stress the
importance of correctly administrated PD drugs and to
prevent complications might result in less deterioration.
Rigid electronic medication systems in hospitals do not
seems to support home schedules of PD medication.
Self-administration of PD drugs by able patients could
be an option. The effects of an electronic warning sys-
tem to alert the treating team of the vulnerability of this
patient group, and a multidisciplinary approach, with a
role for the clinical pharmacist and movement disorder
team, should be evaluated in future studies.
This study has a number of limitations. Information
was asked about the previous year, causing possible
recall bias. Medication administration was assessed
through self-report, and patients who died during
admission were obviously not included. Since it was
not possible to uncover adverse medication prescrip-
tion during the admissions this aspect was not taken
into account. Further studies should be undertaken to
shed more light on these aspects. Nevertheless, we
believe that these limitations do not invalidate our
conclusions.
Gerlach et al. BMC Neurology 2012, 12:13 Page 6 of 6
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Conclusions 5. Magdalinou KN, Martin A, Kessel B: Prescribing medications in Parkinson’s

This is the first study systematically analysing different
risk factors for deterioration of hospitalized PD patients
both for admissions with and without surgery. There is
a high rate of deterioration during hospitalization of PD
patients on all wards. Especially incorrect medication
distribution, but also infections are related to this. Mea-
sures should be taken to improve care and should be
incorporated in guidelines.
Additional material
Additional file 1: Introduction letter for questionnaire. Introduction
letter for PD patients for the questionnaire.
Additional file 2: Questionnaire. Questionnaire for PD patients.
disease (PD) patients during acute admissions to a District General
Hospital. Parkinsonism Relat Disord 2007, 13:539-540.
6. Mehta S, Vankleunen JP, Booth RE, Lotke PA, Lonner JH: Total knee
arthroplasty in patients with Parkinson’s disease: impact of early
postoperative neurologic intervention. Am J Orthop 2008, 37:513-516.
7. Chou KL, Zamudio J, Schmidt P, Price CC, Parashos SA, Bloem BR, Lyons KE,
Christine CW, Pahwa R, Bodis-Wollner I, Oertel WH, Suchowersky O,
Aminoff MJ, Malaty IA, Friedman JH, Okun MS: Hospitalization in Parkinson
disease: A survey of National Parkinson Foundation Centers. Parkinsonism
Relat Disord 2011, 17:440-445.
8. Gerlach OH, Rouvroije VJ, Weber WE: Parkinson’s disease and
hospitalization: The need for guidelines. Parkinsonism Relat Disord 2011,
17:498.
9. Tomlinson CL, Stowe R, Patel S, Rick C, Gray R, Clarke CE: Systematic
review of levodopa dose equivalency reporting in Parkinson’s disease.
Mov Disord 2010, 25:2649-2653.
10. Krahenbuhl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J,
Krahenbuhl S: Drug-related problems in hospitals: a review of the recent
literature. Drug Saf 2007, 30:379-407.

Acknowledgements
We wish to thank I.Muskens, medical student, and the nurse specialists M.
Waber, T.Lustermans, V. Vleugels, A.van den Bemt and H.Bongenaar for
collecting data. We thank all patients for their time and effort to return the
questionnaires.
There was no financial support for the study.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2377/12/13/prepub
doi:10.1186/1471-2377-12-13
Cite this article as: Gerlach et al.: Deterioration of Parkinson’s disease
during hospitalization: survey of 684 patients. BMC Neurology 2012 12:13.

Author details
1
Section of Movement Disorders, Department of Neurology, Maastricht
University Medical Centre, Maastricht, The Netherlands. 2Section of
Movement Disorders, Department of Neurology, Orbis Medical Centre,
Sittard-Geleen, The Netherlands. 3Section of Movement Disorders,
Department of Neurology, Catharina Hospital Eindhoven, Eindhoven, The
Netherlands.

Authors’ contributions
OHHG and WEJW participated in design, data collection, interpretation of
the data, and prepared the manuscript. MPGB participated in data collection,
interpretation of the data, and prepared the manuscript. PHMFD and AJV
participated in data collection and helped to bring the manuscript to its
final version. All authors read and approved the final manuscript.

Competing interests
Oliver H.H. Gerlach, Martijn P.G. Broen and Ad J. Vermeij do not have any
financial or other conflict of interest. Peter H.M.F. van Domburg has served
on scientific advisory boards for Novartis and Lundbeck Inc. Wim E.J. Weber
is European research editor of British Medical Journal.

Received: 5 September 2011 Accepted: 8 March 2012

Published: 8 March 2012

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